Failure to Use Gait Belt During Transfer and Improper Food Tray Handling
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to use a gait belt while transferring a resident with Parkinson's disease, hypertension, and diabetes mellitus from bed to walker and while assisting the resident to the bathroom. The resident required moderate assistance with transfers and was care planned for one-person assist with a gait belt and adaptive devices as recommended by therapy or medical providers. During the observed transfer, the CNA used improper techniques, including pulling the resident by the arm and pants, and did not utilize a gait belt, resulting in the resident becoming unsteady and nearly losing balance. The CNA was unable to explain where to obtain a gait belt and did not confirm receiving training on its use. Additionally, surveyors observed a food cart with nine used food trays and cutlery left unattended in a resident hallway after meals. Staff interviews confirmed that trays were left out for residents who preferred later meals, but acknowledged that this practice posed risks, including the possibility of residents consuming food not intended for them and infection control concerns. Facility staff, including the DON, administrator, and unit manager, confirmed that food trays should be removed from hallways and placed in the kitchen after meals. Review of facility policy indicated that a gait belt should always be used when transferring residents, and staff should seek assistance if unsure of the transfer process. The facility did not have a specific policy on accidents and hazards. The failure to use proper transfer techniques and to promptly remove food trays from hallways were directly observed and confirmed by staff interviews and record review.